Extraction of an ectopic supernumerary tooth through nasal cavity with piezosurgery under local anesthesia: A case report

Key Clinical Message The ectopic supernumerary teeth (ST) commonly occur in the oral cavity. Ectopic ST in the maxilla can be extracted not only through an intraoral approach but also through a nasal approach. Abstract The ectopic supernumerary teeth (ST) commonly occur in the oral cavity. We are reporting a case of a 23‐year‐old female patient with one ectopic ST in the anterior midmaxillary region. We extracted the ectopic ST under local tissue anesthesia through the nasal cavity using piezosurgery and minimally invasive extraction tools. During the operation, the adjacent structures remained intact, and the patient discomfort. This case indicates that ectopic ST in the maxilla can be extracted not only through an intraoral approach but also through a nasal approach.


| INTRODUCTION
Supernumerary teeth (ST) refer to extra teeth beyond the normal dental formula.2][3][4][5] However, the occurrence of ectopic ST is exceedingly rare, with only up to 1% of cases being reported. 68][9] ST often lead to impacted, delayed, and abnormal eruption, root resorption, or compression and bending of adjacent permanent teeth in children. 2,3,10Furthermore, odontogenic cysts may form, which can negatively impact children's facial esthetics, chewing function and also mental health. 112][13][14] Hauer et al. 15 used a modified maxillary vestibular approach with subperiosteal intranasal dissection for extracting an impacted ST and concluded that this approach can reduce postoperative complications.The advantage of the nasal approach is the lower incidence of postoperative complications and shorter surgical time.In addition, the surgical wound, bone removal, and risk of damage to the roots of upper incisors and the nasopalatine neurovascular bundle are minimized. 16In this study, we successfully extracted the ectopic ST through the nasal approach.
Studies have shown that piezosurgery 17 can selectively perform cutting functions.When piezosurgery encounters vessels, nerves, or other soft tissues, piezosurgery stops working.Some studies have concluded that piezosurgery reduces surrounding tissue damage, promotes tissue repair and stimulates cells, facilitates tissue metabolism, and promotes bone regeneration.][20][21] Most previous studies 15,22,23 extracted the impacted maxillary anterior ST with general anesthesia, with only a small number of cases treated with local anesthesia. 6here some complications of general anesthesia 24 including aspiration, bronchospasm, postoperative nausea and vomiting, sore throat, enamel fracture, avulsion and crown fracture.In this present study, the ST was extracted under local anesthesia with no complications, and the patient was very cooperative.In this case, we aim to study the advantages of using piezosurgery to extract ectopic teeth through a nasal approach under local anesthesia.

| CASE HISTORY/ EXAMINATION
A 23-year-old female patient presented to our department who was referred from the Department of Orthodontics to extract the ST.Upon examination, the ST were not palpable in the nasal cavity (Figure 1).The patient was asymptomatic and denied any pain, smell disturbances, postnasal drip, and previous history of maxillofacial trauma or surgery.

| METHODS (INVESTIGATIONS AND TREATMENT)
Ancillary examination using cone beam computed tomography (CBCT) showed that the ST was visible at the tip of the left maxillary central incisor's root, which was extremely close to the incisal foramen and nasal floor (Figure 2).Surgical Procedure: We performed an infraorbital nerve block anesthesia (Figure 3A).After the anesthesia took effect, we made a surgical incision (Figure 3B).After exposing the operative area, we used piezosurgery to remove bone (Figure 3C,D).We extracted the ST using a minimally invasive method and sutured the wound (Figure 3E,F).

(OUTCOME AND FOLLOW-UP)
After the extraction of ST (Figure 3G), we took a pantomography (Figure 4).The suture was removed 1 week after the operation.

| DISCUSSION
During the extraction of an ectopic ST in the maxillary region, ST can be extracted from the nasal cavity in addition to the conventional intraoral surgical approach.According to a study, 16 compared to conventional surgery, transnasal endoscopic approach had fewer postoperative complications and reduced operative time.In a study by M. Clementinile, 23 a 9-year-old child had a ST extracted from the nasal cavity by means of an endoscopic approach, and it was concluded that the nasal cavity may provide another surgical approach.In our case, we extracted the embedded ectopic ST through the nasal approach, which reduced intraoperative bleeding and bone removal and alleviated postoperative complications.
Stbinger et al. 25 found that the application of piezosurgery during the operation greatly reduces the amount of bleeding.Application of piezosurgery to the extraction of ST also can reduce postoperative pain, facial swelling, the amount of bone removal, and intraoperative bleeding, thereby relieving patient anxiety and fear. 21Similar conclusions were drawn in this case, as the patient experienced minimal intraoperative bleeding, less debridement and osteotomy, mild postoperative symptoms and good intraoperative cooperation.
In previous studies, 15,16,22,23 most of the ST was extracted using a transnasal endoscopic approach with general anesthesia.However, this approach may affect the nasal mucosa, such as causing injury to the nasal septum and resulting in massive nasal bleeding.General anesthesia may cause airway compromise or aspiration, and the postoperative reaction can be severe.We extracted the ST under local anesthesia through a nasal approach, which not only reduced the possibility of damage to adjacent teeth and nerves, but also reduced postoperative bleeding, pain, swelling, and other complications.Furthermore, it also shortened the patient's overall treatment period.In the present case, extraction of an ectopic ST through the nasal cavity using piezosurgery under local anesthesia was performed successfully, with no other additional surgical procedures.During the operation, the adjacent structures remained intact, without any other complication and the patient was very cooperative.

| CONCLUSION
Extracting ST through the nasal cavity has a low postoperative morbidity and a low risk of complications due to smaller surgical wounds, minimal exposure, less debridement and osteotomy, and reduced the risk of injury to upper incisor root and nasopalatine neuromuscular bundle compared to other techniques.This study demonstrated that the nasal cavity approach with piezosurgery is a useful approach for the exposure and removal of impacted ST, which reduces postoperative morbidity and provides a surgical approach for oral and maxillofacial surgeons.

F I G U R E 2
Preoperative CBCT images of the patient.(A)Preoperative pantomography; (B) cross section; (C) longitudinal section; (D) horizontal position.F I G U R E 3 Operation process.(A) Infraorbital nerve block anesthesia was performed; (B) a surgical incision was made; (C, D) piezosurgery was used to remove bone after exposure of the operative area; (E, F) the wound was sutured after the ST extracted by a minimally invasive method; (G) the extracted ST.